A Field Guide to the FRACP Written Exam
^ The angry, miserable individual who you think is writing the questions
Twice a year, once in February and once in October, several hundred of Oceania's most competent young doctors file into examination centres, surrender their phones, and remove anything digital from their wrists. Per College regulations, only analogue watches are permitted, which means the room horologically reverts to about 1987. Then, for most of the day, people who routinely make decisions about other humans' potassium fret about filling in small circles with a pencil.
This is the RACP Divisional Written Examination, or DWE, known to most as simply "the written." It is the gate at the end of Basic Physician Training, and it has acquired the kind of mythology gates usually acquire. The mythology is mostly unhelpful. The exam itself, it turns out, is knowable, its shape is public and demystifying it is the first step to confidence on that day and elation a short while after.
The shape of the thing
The written is two papers, sat on the same day.
Medical Sciences is the shorter paper: around 70 questions, mostly single-best-answer multiple choice with a handful of extended matching questions. It examines the principles underneath what we do everyday. It covers physiology, pharmacology, genetics, statistics, the machinery of the body and of evidence. Here is where you draw your memory back to things you last considered in second-year medical school.
Clinical Applications is the long one: 100 questions, again mostly single-best-answer with some EMQs, testing the clinical side of medicine and therapeutics across every specialty a general physician might touch. It can feel haphazard. Cardiology followed by a rash, which gives way to a confidence interval, before a man with hyponatraemia who refuses to have a simple problem.
All up, 170 questions and about six hours of examination time, with reading periods before each paper. Treat the RACP's page for your exam date as the only source of truth on logistics, but the architecture above has been stable for years.
So, who writes it all?
It is tempting, around question 140, to imagine the exam is written by a single malevolent force in a basement. The reality is quite the opposite. Questions come from Item Writing Panels. These are groups of twenty-plus specialists who meet over the year to draft, argue over, and frequently reject each other's questions. No question reaches your desk without some careful consideration.
More importantly: the exam is criterion-referenced. You are not competing against loud cougher two desks over. The pass mark is set against a defined standard. The College uses the Modified Angoff method, in which experts estimate how a just-barely-competent candidate would perform on each question. This is further stabilised across sittings with statistical anchoring, so that an unusually savage paper doesn't produce an unusually savage result. In recent sittings, roughly three in four candidates have passed. The exam is definitely hard and stressful, but the numbers are on your side.
The anatomy of a question
The single-best-answer question is a small literary form, and like most literary forms it has conventions. There is firstly a stem, the clinical vignette, often a paragraph of careful misdirection in which a 64-year-old presents with something. Then there is a lead-in: the actual question, frequently containing the load-bearing words most likely or best next step, which candidates skim at their peril. And there are four options: one correct answer and three distractors.
The distractor deserves respect. A good one is not wrong so much as almost right. It is what you would do if you'd read the stem slightly carelessly, or what was standard practice eight years ago, or what the patient's daughter is demanding. Distractors are designed to be plausible. Learning to see them as a genre, to ask, of a tempting option, whose mistake is this designed to catch?, is one of the skills the best-prepared candidates develop, and it only develops through volume.
The EMQ, by contrast, is a slightly different beast. It is a question with a large cast of options, and a series of short scenarios, each of which must be matched to its correct player. It rewards the same thing the whole exam rewards, which is pattern recognition backed by actual knowledge, in that order of speed and that order of importance.
The room
Practical intelligence: the exam is paper-based, at venues across Australia and New Zealand. Calculators are not permitted, any arithmetic is designed to be done by hand, a fact worth internalising before you meet a number-needed-to-treat question with rising panic. You may write on the question booklet once reading time ends, but only the official answer sheet is marked. Make sure you check your answers sync up. The saddest species of exam failure is the person with the right answers in the wrong place.
What is it actually testing?
Strip away the folklore and the written exam is asking one question 170 different ways: can this person be trusted with breadth? Advanced training will give you a deep specialization. Basic training, and this exam, exist to certify that you are safely, genuinely broad. It exists to make sure that the future cardiologist still recognises the myeloma, and the future rheumatologist still respects the ECG.
The questions often have much less detail and are more complicated than American and British physician exams. I used to hate this, but have realised that this is the genius of the written exam. Rarely in clinical practice do we get the full exam results, investigations and history presented to us. It's more often a phonecall taken at bleary-eyed hours of the morning from someone who does not understand the ins and outs of hyponatraemia. Being able to quickly identify important information is a real skill that is very satisfying once you master it.
Seen that way, the format stops being an ordeal and becomes a blueprint. The College literally publishes an exam blueprint, listing the approximate distribution of questions by specialty. Reading it should be the first hour of anyone's preparation. The exam tells you in advance how it weights each section of knowledge. Very few of life's tests are so courteous.
*FRACP Vault exists for the volume part: 1,500+ consultant-written questions in the RACP style, each with a detailed explanation. A further 6 practice papers (3 clinical applications and 3 medical science). Try 50 sample questions at fracpvault.com.au.